Provider Demographics
NPI:1275823478
Name:BALASSA, ENIKO
Entity Type:Individual
Prefix:
First Name:ENIKO
Middle Name:
Last Name:BALASSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-2512
Practice Address - Country:US
Practice Address - Phone:989-846-4508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist